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Hindawi Publishing CorporationCase Reports in OrthopedicsVolume 2012, Article ID 691703, 4 pagesdoi:10.1155/2012/691703

Case Report

Gemella haemolysans Infection in Total Hip Arthroplasty

Barry Rose,1 Parminder J. S. Jeer,1 and Anthony J. Spriggins2

1 Department of Orthopaedics, Queen Elizabeth The Queen Mother Hospital, East Kent Hospitals NHS Foundation Trust, St. PetersRoad, Margate, Kent CT9 4AN, UK

2 Orthopaedic Department, SPORTSMED. SA, 32 Payneham Road, Stepney, SA 5069, Australia

Correspondence should be addressed to Barry Rose, [email protected]

Received 29 December 2011; Accepted 15 March 2012

Academic Editors: K.-I. KIM, S. A. Papadakis, and S. N. Parikh

Copyright © 2012 Barry Rose et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gemella haemolysans is a Gram-positive coccus and commensal of the upper respiratory tract and oral mucosa that rarely causesclinically important infections. There is only one previous report of this organism causing periprosthetic infection, in a total kneearthroplasty. We present a case of septic loosening of an uncemented total hip arthroplasty due to G. haemolysans, in an asplenicpatient with insulin dependent diabetes mellitus. Treatment with two-stage revision has been successful at 7 years of follow-up.

1. Introduction

Deep late infection following total hip arthroplasty (THA)is an uncommon but devastating complication. There arenumerous factors associated with such infections, includingthose related to both the host immunologic status and theinfecting organism. The adverse effects of hyperglycaemiain diabetic patients [1] and asplenia [2] as risk factorsfor infection are well recognised. The organisms mostcommonly isolated in deep infection following THA areStaphylococcus aureus and Staphylococcus epidermidis [3, 4].Gemella haemolysans is a Gram-positive bacterium andnormal commensal of the upper respiratory tract and oralmucosa. It is being increasingly isolated as the causativeorganism in a number of infections, including meningitis,cerebral abscesses, endophthalmitis, keratitis, pneumonia,endocarditis, glomerulonephritis, and peritonitis [5–13]. Itis extremely rare for this organism to cause infections ofan orthopaedic nature, with only three reports of spinalinfections [14–16], and a single report of infection in a totalknee arthroplasty (TKA), which occurred in a patient withrheumatoid arthritis [17]. We report the first case of septicloosening in THA due to G. haemolysans infection 5 yearsfollowing the uncomplicated primary surgical episode.

2. Case Report

A 40-year-old male with primary hip osteoarthritis under-went left THA in October 1997 using an uncementedprosthesis with a polyethylene bearing surface. The patienthad been an insulin-dependent diabetic since 1986 and in1994 had undergone splenectomy following complicationsduring a Nissen fundoplication. As a result of this, he hadreceived antipneumococcal vaccination, but despite rec-ommendations to take a regular dose of empirical phe-noxymethylpenicillin, he admitted poor compliance withthis.

Prior to THA, routine urine and sputum cultures werefree of infection, and his blood sugar levels revealed gooddiabetic control. He had been examined by a senior physicianand had no cardiorespiratory problems. The THA procedurewas covered with intravenous phenoxymethylpenicillin, gen-tamicin, and cefuroxime at induction, and these were contin-ued to the third postoperative day, followed by resumption oforal phenoxymethylpenicillin prophylaxis. His postoperativecourse was unremarkable, with no wound complications.Clinical and radiographic review on a yearly basis to October2001 was satisfactory.

At five years after surgery he presented with acute leftgroin pain with radiation to the thigh without history of

2 Case Reports in Orthopedics

antecedent trauma. He stated that he had felt lethargic andthat his blood glucose levels had recently been elevated anddifficult to control.

Examination revealed no evidence of hip wound infec-tion and a pain-free range of hip movement. He was foundto be pyrexial with a temperature of 37.9◦C and had a whitecell count of 16.6 × 109/L, an erythrocyte sedimentationrate (ESR) of 98 mm/hr, and a C-reactive-protein of 89 mg/L(normal range <10 mg/L). His diabetic control was poor withan HbA1C percentage >11%. Subsequent urine, sputum, andblood cultures did not reveal any focus of infection, as wasthe case with physical examination of all other body systems.Plain radiographs of the left hip revealed no obvious signs ofloosening or fracture.

A bone scan revealed a focus of hyperaemia in the regionof the acetabulum in the early blood pool frames and delayedimages revealed increased activity around the femoral com-ponent in Gruen zone 7. A Gallium scan revealed moderatelyincreased isotopic activity at the superolateral aspect of theacetabular component and around the proximal femur inGruen zones 1 and 7. The hip was aspirated in theatrerevealing turbid fluid, and cultures after five days of incu-bation revealed G. haemolysans. The organism was sensitiveto penicillin with a minimum inhibitory concentration of0.06 mg/L.

An exploration of the hip joint was performed with aview to performing a two-stage revision if there was evidenceof component loosening. At surgery antibiotic prophylaxiswas not withheld in view of the risk of overwhelmingsepsis in an asplenic patient, and high-dose intravenousbenzylpenicillin was administered. The hip joint was foundto be obviously infected, and pus sent for microbiologicalanalysis along with multiple tissue specimens. The acetabularcomponent was loose and easily removed. There was osteol-ysis around the proximal femur, but the femoral componentwas well fixed distally and required a femoral osteotomyto be removed. The hip was debrided and irrigated withhydrogen peroxide, povidone iodine, and saline impregnatedwith flucloxacillin at 2 g/L concentration, and a PROSTALAC(prosthesis of antibiotic-loaded acrylic cement) gentamicinfemoral spacer (Depuy, Warsaw, Indiana) was inserted. Allintraoperative fluid and tissue samples grew a pure isolate ofG. haemolysans sensitive to penicillin.

Intravenous penicillin treatment was continued for sixweeks at which time the patient was systemically well,with improved diabetic control and uncomplicated woundhealing. The inflammatory markers had improved with anESR of 18 mm/hr and a CRP of 17 mg/L. The second-stage revision was performed at this stage, using a longstem uncemented femoral component and an uncementedacetabular prosthesis. There were no intraoperative signsof infection and tissue samples from this procedure failedto grow any organisms. This procedure was again coveredwith intravenous benzylpenicillin which was continueduntil discharge at two weeks, followed by high-dose oralphenoxymethylpenicillin (1 g six hourly) for four weeks. At7-year follow-up, clinical and radiographic reviews have beensatisfactory, with normalisation of inflammatory markers.

3. Discussion

G. haemolysans was first described in 1938 by Thjotta andBoe as Neisseria haemolysins [18] and later allocated aseparate genus by Berger, following enzymatic studies [19].The chemical composition of the peptidoglycan of G.haemolysans is identical to that of Gram-positive bacteria[20]. It is a catalase negative, facultative anaerobe coccus,which resembles and has an IgA protease similar to Strep-tococcus viridans [21]. The organism may be identified by aseries of biochemical reactions (API 20 Streptococcus iden-tification system, BioMerieux, Marcy l’Etoile, France) andGram-staining [17]. However, identification of this organismcommonly presents difficulties as solely biochemical analysismay produce erroneous identification. In this case, initialcharacterisation was performed using the API-ZYM sys-tem (BioMerieux, Marcy l’Etoile, France) supplemented byadditional biochemical testing. Definitive identification wasconfirmed using 16S ribosomal RNA gene sequencing [22].

G. haemolysans is a normal commensal of the upperrespiratory tract and found in approximately 30% of healthyadults in the nasopharyngeal mucosa [23]. The reportedcases of G. haemolysans in the literature have occurred inimmunocompetent patients [5–16], although the single caseof infection following TKA was in a rheumatoid patient witha history of treatment with disease modifying antirheumaticdrugs [17]. This patient was successfully managed with atwo-stage revision and penicillin antimicrobial chemother-apy.

There have been three case reports of G. Morbillorum-infected arthroplasties (two hips, one elbow) [24–26], whichis closely related to G. haemolysans. All three were success-fully managed by two-stage revision surgery. Two furthercases of G. morbillorum septic arthritis (one hip, one knee)[27, 28] and one of spondylodiscitis with epidural abscessfollowing an acute lumbar vertebral fracture [29] have alsobeen described.

The onset of late deep infection in this case suggests ahaematologic cause [3, 30, 31]. Although our patient didnot have any history of recent dental surgery or obviousdental hygiene problems prior to presentation, the mostlikely explanation for this haematologic cause is a transientbacteraemia, and this is more likely in a patient with poordental health [32, 33].

Asplenic patients are at an increased risk of infectionwith encapsulated bacteria. There is evidence that lifelongantibiotic prophylaxis with penicillin may reduce the risk ofinfection but not entirely eliminate it [34]. Our patient waspoorly compliant with penicillin prophylaxis. However, G.haemolysans is not an encapsulated organism. As such, theasplenic status of this patient is unlikely to be of significance,unless another unidentified organism was in part responsiblefor the infection. Poor diabetic control is more likely to havecontributed to the risk of a periprosthetic infection.

4. Conclusion

G. haemolysans is an extremely rare cause of periprostheticinfection in immunocompromised hosts. This rarity may

Case Reports in Orthopedics 3

be related to difficulties characterising it using traditionalmethods. Periprosthetic infection with this organism can besuccessfully managed with two-stage revision combined withantibiotic treatment.

Conflict of Interests

The authors have no conflict of interests to disclose. Potentialconflicts do not exist.

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